Analysis and Adjustment of Vertebral Subluxation as a Separate and Distinct Identity for the Chiropractic Profession: A Commentary.

OBJECTIVE: The purpose of this paper is to discuss various statements related to chiropractic identity from1 D. D. Palmer2; selected chiropractic organizations, associations, and colleges; and3 attitudes and perceptions of chiropractic from chiropractic students, practitioners, and patients. DISCUSSION: For comparison purposes, identity statements and perceptions from the various chiropractic associations and colleges, as well as from students and patients, were explored. Identity statements for chiropractic were searched in various sources such as Palmer's 1910 textbook, recent literature on viewpoints from chiropractic students and practitioners, and websites for chiropractic colleges and organizations. Palmer taught that the chiropractor's focus was on vertebral subluxation. Today, a number of chiropractic colleges and organizations continue to include the vertebral subluxation model in their instruction, with a majority of students and practitioners subscribing to the model. Conversely, a number of other colleges and organizations portray chiropractic as being essentially about the treatment of back and neck pain, which is what patients associate with chiropractic. However, settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as "functional neurology."
CONCLUSION: When a profession's identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and, therefore, might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.

Introduction

Two basic considerations are necessary to identify a profession: its central area of interest and its mission. Although not the only things that identify a profession, these are necessary before other prerequisites of a profession are obtainable. Others hold that the definition of a profession pertains to its area of knowledge and boundaries of that knowledge, otherwise known as “degree of abstraction.”

As a practical matter, identity of a profession helps guide its practitioners on scope of practice issues and informs the public on what the profession has to offer. Moreover, without a clear identity, there tends to be confusion about the profession. This confusion could manifest in the minds of patients, students, and practitioners.

Professional identity includes a self-concept of values, beliefs, and experiences. Moreover, the formation of a professional identity goes beyond the acquisition of certain skill sets, as it is formed mainly in social and relationship contexts. Having an identity that satisfies these descriptions still may not be satisfactory if that identity is not unique, separate, and distinct from those of other professions. One obstacle to achieving a clear and unified chiropractic identity has been that of “oppression,” as some in the nursing profession have observed. In the chiropractic context, the oppression pertains to opposition by organized medicine. Medical regulation was used against chiropractors, and many were arrested for practicing medicine without a license. The actions of the brave chiropractic pioneers, who went to jail for chiropractic to protest the charge (and who were practicing chiropractic, not medicine), helped bring about licensure in the United States. During the tumultuous days of harassment by organized medicine, chiropractic identity may have been diluted from the oppression. Another important aspect in professional identity is obtaining trust from the public that the profession serves. This trust requires periodic renewal of a profession’s social contract with the public. Without such renewal, the public will wrest the contract from the profession’s control and shift it to the “default model of the market.”

When 2 professions have identities that are the same or overlap substantially (eg, both have back pain as their area of focus), then 1 of the professions is duplicative and therefore unnecessary. Some say that back pain is the main area of interest in chiropractic. Although back pain may not be the main area of interest in all medical practices, it certainly is included as 1 of their areas of interest. When chiropractors identify themselves as back pain specialists, or even spine specialists, they compete not only with medical practitioners, but also with osteopaths, physical therapists, massage therapists, and medicine cabinets in the homes of millions of potential patients. Others have suggested that the chiropractic identity be centered on the spine. However, such an identity is vague and also covered by other health professions. As Abbott has suggested, larger professions will tend to dominate the field. Thus, for the chiropractic profession, if its identity is based on neck and back pain, it is lost in the presence of much larger professions (eg, medicine) that also treat back and neck pain. Moreover, when the osteopathic profession merged into orthodox medicine in the late 1950s, it ceased to offer a unique service and was essentially swallowed up by the medical profession. Today, the osteopath and medical doctor are virtually indistinguishable.

The purpose of this paper is to discuss various statements related to chiropractic identity from D. D. Palmer; selected chiropractic organizations (associations) and colleges; and attitudes and perceptions of chiropractic from chiropractic students, practitioners, and patients. The article concludes by encouraging the profession to base itself on its original intent, which is improving neurologic function by adjustment of vertebral subluxation.

Discussion

For the purpose of this commentary, identity of chiropractic is considered synonymous with definition or explanation of what chiropractic is. Definitions of chiropractic, or statements that at least resembled a definition, were obtained from Palmer’s famous 1910 book, The Science, Art, and Philosophy of Chiropractic92; websites of national and international chiropractic organizations; websites of chiropractic colleges listed in English by the Association of Chiropractic Colleges; and internet (Bing, PubMed, and Google Scholar) searches for reported attitudes of chiropractic students, practitioners, and patients. The associations comprised the Association of Chiropractic Colleges (ACC), American Chiropractic Association, International Chiropractors Association, International Federation of Chiropractors and Organizations (IFCO), and World Federation of Chiropractic (WFC).

The Founder of Chiropractic

Throughout Palmer’s 1910 textbook, he essentially stated that the main area of interest and therefore identity in chiropractic was analysis and adjustment of vertebral subluxation.

Chiropractic Organizations

Among a sample of 5 major chiropractic organizations, 2 specifically mention that chiropractic’s focus is subluxation (ACC) or vertebral subluxation (IFCO). Another organization’s statement is similar in that it mentions spinal adjustment, nervous system function, and general health, without specifically using the term subluxation (WFC) (Table 1).

Table 1

Definitions (Identities) of Chiropractic From 5 National and International Chiropractic Associations

Association of Chiropractic Colleges (ACC)	“Chiropractic is a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery. The practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In addition, Doctors of Chiropractic recognize the value and responsibility of working in cooperation with other health care practitioners when in the best interest of the patient. Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”10
American Chiropractic Association (ACA)	“Doctors of Chiropractic establish a doctor/patient relationship and utilize adjustive and other clinical procedures unique to the chiropractic discipline. Doctors of Chiropractic may also use other conservative patient care procedures, and, when appropriate, collaborate with and/or refer to other health care providers."11
International Chiropractors Association (ICA)	“The anatomical focus of the DC on the human spine has created the perception of the DC as just a back doctor. Although this perception is not entirely incorrect, it is very much incomplete. Doctors of chiropractic are a highly appropriate resource in matters of work-place safety, stress management, injury prevention, postural correction and nutritional counseling.”12
International Federation of Chiropractors and Organizations (IFCO)	“Chiropractic [is] a separate and distinct profession dedicated to the detection and correction of vertebral subluxation for the better expression of life.”13
World Federation of Chiropractic (WFC)	“A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation.”14

Chiropractic Colleges

A search of the internet was performed in February 2016 on how chiropractic colleges represent themselves and chiropractic identity to the public. Among the chiropractic colleges, 3 specifically mention subluxation in their description of chiropractic: Life University, Life Chiropractic College West, and Sherman College of Chiropractic. Other colleges, such as Cleveland Chiropractic College, New Zealand College of Chiropractic, and Palmer College of Chiropractic, describe subluxation with statements related to chiropractic focusing on the spine and its relationship to the nervous system. A number of other colleges mention that chiropractic pertains to general health and/or musculoskeletal conditions (Table 2).

Table 2

Definitions (Identities) From Selected Chiropractic College Internet Sites

Canadian Memorial Chiropractic College	No definition seen.26
Cleveland College of Chiropractic	“Importance [is placed] on the science of the structure and function of the human body, blended with a philosophy for a hands-on approach to health and natural healing. It is a holistic approach. To that – our teachings focus on the importance of spinal function and its relationship to the nervous system and good health. We emphasize that the body is a self-regulating and self-healing organism. Our goal is to use spinal and extremity adjusting techniques, along with advice regarding diet, exercise and positive lifestyle choices, to help the body help itself.”27
Life Chiropractic College West	“Chiropractic is a natural and non-invasive form of health care that is based on the principle that the body has the inherent ability to heal without the use of drugs or surgery. This fundamental approach to wellness mirrors a new and changing attitude toward health care in the United States and around the world. Through chiropractic adjustments, nervous system interference due to abnormalities in the musculoskeletal relationships of the vertebrae (called subluxations) can be corrected. This allows the nervous system to function properly, enabling the body to heal through its own natural recuperative powers.”28
D’Youville Chiropractic College	“Chiropractic is a healthcare profession focusing on disorders of the musculoskeletal and nervous systems.”29
Life University	“Chiropractic is a philosophy of health, a science of the nervous system and spine, and an art of helping people regain their health naturally. It recognizes that all organic systems in the universe are conscious, self-developing, self-maintaining and self-healing. Chiropractic believes that the body works best when the nervous system is free of damaging interferences, which cause malfunction, symptoms and diseases, and a reduced quality of life. It observes that there are three interferences: physical trauma, emotional stresses and environmental toxins. One of these interferences is called subluxation. Chiropractors correct subluxation, allowing your nervous system to function more normally, releasing your body’s innate potential to regain health naturally and paving the way for you to experience wellness throughout life.”30
Logan University	“Doctors of Chiropractic treat the whole person and are poised to provide a positive impact on their patient’s health, performance and quality of life. Chiropractors offer less invasive, non-surgical treatments that do not rely on prescription drugs. While many chiropractors focus on care for the entire family, Doctors of Chiropractic can also focus their practice on specialty care. Areas of focus include sports, neurology, pediatrics, orthopedics, nutrition or radiology.”31
National University of Health Sciences (Florida and Illinois campuses)	“Chiropractic medicine is a comprehensive health care profession that addresses the wide variety of factors that impact upon human physiology. Chiropractic physicians specialize in natural, non-invasive health care and are trained to use a full range of medical diagnostic tools and a wide array of effective treatment options in patient care.”32
New York Chiropractic College	Chiropractic “place[s] special emphasis on neuromusculoskeletal conditions and overall patient wellness.”33
New Zealand College of Chiropractic	“Chiropractic is about helping the body to work at its best. Your nerve system, which controls all the functions of your body, is protected by your spine. Sometimes the stresses and strains of daily life can cause an imbalance between the vertebra and the nerve system, which may cause interference to the messages being carried by the nerves from the brain to the rest of the body. By making small adjustments to the spine, chiropractors can help the body to remove these interferences so that the messages to all the body parts are more accurate. The philosophy is simple: if your nerve system is working properly the body is better able to heal itself and perform at its full potential. A healthy relationship between the spine and nerve system can help anyone at any time in their life, regardless of age, condition or symptoms.”34
Northwestern Health Sciences University	“Chiropractic focuses on neuromusculoskeletal disorders while promoting health and wellness. Doctors of chiropractic are healthcare professionals who view health and illness from a holistic perspective. Musculoskeletal structures, body function and the nervous system are closely interrelated - disturbances in one system can impact the others, affecting health and well-being. They believe the human body possesses an inherent ability to heal itself. By using non-drug, non-surgical treatment methods, body function can be restored or rehabilitated - and further disability can be prevented.”35
Palmer College of Chiropractic (Davenport, Florida, and California campuses)	“Chiropractic is a natural form of health care that uses spinal adjustments to correct these misalignments and restore proper function to the nervous system, helping your body to heal naturally. Chiropractic doesn’t use drugs or surgery. Rather, a chiropractic spinal adjustment - the application of a precise force to a specific part of the spinal segment - corrects the misalignment, permitting normal nerve transmission and assisting your body to recuperate on its own.”36
Parker University	No definition seen.37
Sherman College of Chiropractic	“Chiropractic is the science, art and philosophy of locating and correcting vertebral subluxations so that the body can heal itself in the most efficient manner. Instead of focusing on specific symptoms, chiropractic works to remove interference from the nervous system, which in turn allows better communication throughout the body.”38
Southern California University of Health Sciences	No definition seen.39
Texas Chiropractic College	Chiropractors “diagnose and evaluate with confidence, communicate effectively with other medical professionals, and skillfully treat patients based on the evidence presented.”40
University of Bridgeport College of Chiropractic	“Chiropractic is a health care profession which concerns itself with the relationship between structure and function of the human body, and how that relationship may affect the restoration and preservation of health. The D.C. program focuses on the neuro-musculoskeletal systems; however, graduates are trained to approach patient health care challenges in a holistic fashion.”41
University of Western States	“The purpose of the doctor of chiropractic degree program is to provide training for students to develop the knowledge, skills, values and behaviors necessary to become primary care chiropractic physicians that apply best evidence, critical thinking, effective procedures, and professional integrity in the delivery of patient-centered care.”42

The Public

Survey research by Gallup and Palmer College indicates that the public generally considers that chiropractic pertains to neck and back pain. However, 31% of those surveyed indicated that they would like to use chiropractic care even if they were asymptomatic. This suggests that about a third of potential patients are open to a wellness approach, which is a component of the vertebral subluxation model (eg, “maintenance care”).

Chiropractic Students

Survey research by Gliedt et al indicates that a majority (61.4%) of chiropractic students think that “the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes.”

Chiropractors

Survey research by McDonald et al indicated that 88.1% of practicing chiropractors in North America who responded to the survey answered yes to the question, “Should chiropractic retain the term vertebral subluxation complex?”

Lack of Consensus

Currently, a consensus viewpoint regarding the identity of the chiropractic profession is lacking, evidenced by the various opinions among its associations and colleges. It is unclear how these varying viewpoints came to be, considering the stated intent and identity of chiropractic as laid down by the founder of the profession. It is possible that these differing views came about simply as a preference that was different from Palmer’s original intent.

Academic freedom allows for various viewpoints, even with respect to a profession’s identity. However, that freedom may come with a price, in the way of unintended consequences; the public may be confused as to what chiropractic is when faced with the variability of viewpoints. Moreover, a profession’s identity that does not make distinctions between its identity and the identities of other professions seems to invite further confusion. To this point, the WFC has recommended that the identity of the profession should be “similar in all countries.”

I feel that this is a worthy recommendation; however, the brand that WFC suggests may be too vague, as it has a relatively high degree of abstraction when it states that chiropractors are “spinal health care experts in the health care system.” The quasi-vagueness here might be considered to be at odds with WFC’s call that chiropractic identity should be clear and concise. Nonetheless, common ground between the WFC and those within the subluxation model are suggested in its qualifying statements for chiropractic care:

Ability to improve function in the neuromusculoskeletal system and overall health, wellbeing, and quality of life;

Specialized approach to examination, diagnosis, and treatment, based on best available research and clinical evidence with particular emphasis on the relationship between the spine and the nervous system;

Tradition of effectiveness and patient satisfaction;

Without use of drugs and surgery, enabling patients to avoid these where possible;

Expertly qualified providers of spinal adjustment, manipulation and other manual treatments, exercise instruction, and patient education;

Collaboration with other health professionals; and

A patient-centered and biopsychosocial approach, emphasizing the mind/body relationship in health, the self-healing powers of the individual, and individual responsibility for health and encouraging patient independence.

Challenges With the Model

I suggest that the chiropractic profession’s identity should be based on what makes it unique and what the founder of chiropractic envisioned it to be, which is adjustment of vertebral subluxations to improve neurologic function in the patient. Although some in the profession have concerns with the subluxation model, there is interest in advancing the profession by addressing these issues.19, 20 For others, the problem may be with the use of the term subluxation. For example, a former president of the National University of Health Sciences states that the purpose of chiropractic manual care is to correct a “functional articular lesion” to “produce (a) beneficial neurologic effect.” Labeling subluxation as a “functional articular lesion” may not necessarily affect the qualities of the entity, if that label carries the same definition as subluxation. Still, it may reduce confusion if consistent terminology were used to describe this unique chiropractic area of interest. Nonetheless, commonality between different factions within the chiropractic profession may begin to merge perhaps on unifying expressions such as “spinal adjustment and functional neurology” or “improving function of the patient’s nervous system through spinal adjustment.” To this end, in moving the argument forward, Table 3 is a compilation of terms and concepts from across the profession that have at least some semblance to the subluxation model.

Table 3

Commonality of Terms From Tables 1 And 2 That Most Chiropractors May Agree on as Being Central to Chiropractic Identity and That Have at Least Some Semblance to the Subluxation Model

Term	Source
Spine and nervous system	Association of Chiropractic Colleges10
Adjustive procedures	American Chiropractic Association11
Spine	International Chiropractors Association12
Vertebral subluxation	International Federation of Chiropractors and Organizations13
Nervous system, spinal adjustment	World Federation of Chiropractors14
Spinal function and its relationship to the nervous system and good health	Cleveland College of Chiropractic27
Subluxation	Life Chiropractic College West28
Musculoskeletal and nervous systems	D’Youville Chiropractic College29
Subluxation	Life University30
Nonsurgical care, neurology	Logan University31
Natural, noninvasive care	National University of Health Sciences (Florida and Illinois campuses)32
Neuromusculoskeletal conditions, overall patient wellness	New York Chiropractic College33
Adjustment, spine, nervous system	New Zealand College of Chiropractic34
Neuromusculoskeletal, health and wellness	Northwestern Health Sciences University35
Spinal adjustment, nervous system	Palmer College of Chiropractic (Davenport, Florida, and California campuses)36
Subluxation	Sherman College of Chiropractic38
Neuromusculoskeletal systems	University of Bridgeport College of Chiropractic41

A perceived problem with the subluxation model is that there are so many definitions for subluxation. Obviously there are many operational definitions for vertebral subluxation. For example, Gonstead has its protocol on how to analyze for subluxation, Activator Methods has its own operational definition, and so on. However, there may be general agreement on the concept definition for vertebral subluxation, which essentially is a minor biomechanical dysfunction in the spine that results in a neurologic disturbance. The various operational definitions highlight the need to include them in papers on subluxation, particularly in research papers, so that other researchers who may wish to verify findings of such studies can do so given enough detail on the methods used. It simply does not suffice to say in a research paper that the spine was examined and adjusted.

Another issue with the subluxation model is the validity and reliability of the methods used to identify it. This challenge though is not unique to the subluxation model, as validity of methods is a challenge in non-subluxation models in chiropractic. For example, the back pain model and the subluxation model may both use motion palpation as a diagnostic method, yet palpation has its own set of challenges regarding its validity (eg, some studies report low reliability). The remedy for such challenges is at the same time an opportunity for different factions of the profession to come together to focus on a common area to advance the profession. As President Abraham Lincoln said, “a house divided against itself cannot stand.” We must join together in our research efforts. An example from the history of chiropractic that unity on subluxation research is possible was the study conducted at the University of Colorado in the 1970s by Sharpless.

One last example of a challenge with the subluxation model is whether subluxation has any adverse effect on health. Because there may be only some evidence along these lines (eg, the Bakris et al study on upper cervical adjustment and hypertension), it would be disingenuous to insinuate that there is none at all. Indeed, even some of the harshest critics of the subluxation model, to their credit, state that it is a “legitimate, potentially testable, theoretical construct.”

Settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as “spinal adjustment and functional neurology.”

Limitations

A limitation to this commentary is that the colleges selected were mostly from one region, North America, the exception being the New Zealand College of Chiropractic. The international “flavor” of what chiropractic is can be viewed by the paper’s inclusion of international associations (eg, WFC and IFCO). Another limitation is that this is an opinion-based paper.

Conclusion

When a profession’s identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and therefore might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): J.H.

Design (planned the methods to generate the results): J.H.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): J.H.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): J.H.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): J.H.

Literature search (performed the literature search): J.H.

Writing (responsible for writing a substantive part of the manuscript): J.H.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): J.H.

Practical Applications

The various identity statements within the profession tend to result in confusion about the purpose of chiropractic care.

The profession should self-identify as having a unique identity and purpose.

To this end, I propose that the traditional identity of the chiropractic profession should be used, namely, the location, analysis, and adjustment of vertebral subluxation.